Higher incidence of perivalvular abscess determines perioperative clinical outcome in patients undergoing surgery for prosthetic valve endocarditis

Abstract

Background: Cardiac surgery for prosthetic valve endocarditis (PVE) is associated with substantial mortality. We aimed to analyze 30-day and 1-year outcome in patients undergoing surgery for PVE and sought to identify preoperative risk factors for mortality with special regard to perivalvular infection. Methods: We retrospectively analyzed data of 418 patients undergoing valve surgery for infective endocarditis between January 2009 and July 2018. After 1:1 propensity matching 158 patients (79 PVE/79 NVE) were analyzed with regard to postoperative 30-day and 1-year outcomes. Univariate and multivariable analyses were performed to identify potential risk factors for mortality. Results: 315 patients (75.4%) underwent surgery for NVE and 103 (24.6%) for PVE. After propensity matching groups were comparable with regard to preoperative characteristics, clinical presentation and microbiological findings, except a higher incidence of perivalvular infection in patients with PVE (51.9%) compared to NVE (26.6%) (p = 0.001), longer cardiopulmonary bypass (166 [76-130] vs. 97 [71-125] min; p < 0.001) and crossclamp time (95 [71-125] vs. 68 [55-85] min; p < 0.001). Matched patients with PVE showed a 4-fold increased 30-day mortality (20.3%) in comparison with NVE patients (5.1%) (p = 0.004) and 2-fold increased 1-year mortality (PVE 29.1% vs. NVE 13.9%; p = 0.020). Multivariable analysis revealed perivalvular abscess, sepsis, preoperative AKI and PVE as independent risk factors for mortality. Patients with perivalvular abscess had a significantly higher 30-day mortality (17.7%) compared to patients without perivalvular abscess (8.0%) (p = 0.003) and a higher rate of perioperative complications (need for postoperative pacemaker implantation, postoperative cerebrovascular events, postoperative AKI). However, perivalvular abscess did not influence 1-year mortality (20.9% vs. 22.3%; p = 0.806), or long-term complications such as readmission rate or relapse of IE. Conclusions: Patients undergoing surgery for PVE had a significantly higher 30-day and 1-year mortality compared to NVE. After propensity-matching 30-day mortality was still 4-fold increased in PVE compared to NVE. Patients with perivalvular abscess showed a significantly higher 30-day mortality and perioperative complications, whereas perivalvular abscess seems to have no relevant impact on 1-year mortality, the rate of readmission or relapse of IE.

Infective endocarditis at a tertiary-care hospital in China

“…Besides these, native valve was the most common involved. Patients undergoing surgical treatment for prosthetic valve endocarditis had a higher 30day and 1-year mortality, when compared to native valve endocarditis [19]. The proportion of congenital heart disease, which was associated with better outcome than other forms of IE [7], was higher in our study [9,10].…”

“…Some studies have also confirmed that these factors were associated with in hospital mortality [8,[22][23][24][25][26]. And perivascular abscess [19], diabetes mellitus [27,28], or acute renal failure [26,29] have also been reported to be the risk factors of high mortality. Interestingly, medical therapy was associated with higher in-hospital mortality, which suggested the protective role of surgical treatment.…”

Virulence of Staphylococcus Infection in Surgically Treated Patients With Endocarditis

“…PVE is a dreadful complication after open-heart valve surgery and has been noted to occur in 1% to 6% after heart valve surgery with an incidence of 0.3 to 1.6 per patient-year. 4 Several studies have identified PVE as an independent risk factor of inhospital mortality, 15,16 with many clinicians considering PVE even a separate disease from native IE. 17 Despite the existing evidence in the literature and the fact that PVE was slightly more prevalent in the Staphylococcus group, PVE was not identified as an independent risk factor.…”

ST-segment elevation myocardial infarction due to septic coronary embolism: a case report

“…Perivalvular abscess formation is associated with a more aggressive disease course and worse outcomes; it is more commonly seen as a complication of PVE, especially aortic PVE, and it appears to occur more often in endocarditis caused by S. aureus . 6 , 7 …”

“…Apart from the management of its possible complications, the mainstay of treatment for infective endocarditis remains appropriate antibiotic therapy and early surgery, which becomes mandatory in cases with locally uncontrolled infection, heart failure or lesion at high risk of embolization. 6 , 7 …”